The Medical Journal of Australia

2 downloads 0 Views 158KB Size Report
Aug 7, 2006 - The Medical Journal of Australia ISSN: 0025-. 729X 7 August 2006 185 3 166- ... into population health, multidisciplinary care and chronic dis-.
T E A CH I N G O N TH E R U N

Teaching on the run tips 14: teaching in ambulatory care Fiona R Lake and Alistair W Vickery Setting

1 Cycle of learning in the outpatient setting3,6,7,9-11

You have agreed to have Year 1 postgraduate doctors attached to your ambulatory practice. You have had undergraduate students attached before, but you are thinking about how to integrate these new doctors into the practice and how to teach both them and the medical student.

Planning

T

rainee doctors and students are increasingly taught in community and outpatient settings, where most patient care now occurs and the mix of patients is appropriate for learning.1-3 Indeed, trainees learn clinical skills just as well in ambulatory as in inpatient settings,2 and experiences in community settings influence doctors’ decisions regarding their future workplace.1,4 Unique opportunities exist for providing insights into population health, multidisciplinary care and chronic disThe Medical Journal of gaining Australiaa ISSN: 0025-understanding of ease management, and for balanced 1,3-5 2006 185 3 166-167 7 August health729X services. Medical Journal in of ambulatory Australia 2006 The©The challenges of teaching settings are different www.mja.com.au from those in inpatient settings. In ambulatory clinics, the pace is Teaching on the Run rapid, with reduced opportunity for direct observation and the potential for lost income.1,3-6 The focus is often on management, and the learner can end up observing rather than doing, being asked questions of factual recall, being given peremptory postconsultation tutorials, or tackling patients with already defined rather than more challenging undifferentiated problems.2,6,7 However, the problems of ambulatory care teaching — variability, unpredictability, immediacy and lack of continuity3,4 — can be avoided with appropriate planning. Importantly, characteristics of the teacher (clinician) as well as the practice influence learning.6-9 The clinician should: • Provide opportunities for learners to assume increasing levels of responsibility (eg, by allowing them to see patients alone); • Provide opportunities for learners to practise practical and problem-solving skills; • Have an appropriate number and variety of patients; • Be enthusiastic, organised and concise, and provide direction; • Be willing to answer questions and explore clinical reasoning; and • Provide timely feedback. The learner expects: • Relevant pre-reading or pre-training; • Learning based on patients; • Allocation of follow-up activities; and • Provision of the necessary resources (eg, computer-based guidelines). The principles of teaching and learning that apply to a single teaching session or clinical attachment apply equally well in an outpatient setting (Box 1) — namely, planning, providing teaching and learning, appraisal, assessment, giving feedback and reflecting on the learner’s experience.10-13 166

• Define course outcomes and methods of assessment. • Consider organisation of the clinic (eg, having a second room available, “wave” scheduling*). • Provide an orientation to: ¾ Clinic and community; ¾ Patient care — expectations; ¾ Learning activities; ¾ Resources (people, Internet-based resources); ¾ Key personnel (practice nurses, educators and other health professionals). Learning • Ensure authentic patient contact. • Pre-select patients for review, based on the experience level of the learner. • Teach through pre-clinic, post-clinic and “case of the week” discussions. • Set aside time for a tutorial. • Use other members of the team for teaching (eg, nurse, patient educator). Appraisal and assessment • Allow direct observation and give feedback. • Use questions to ascertain understanding. Reflection • Consider whether the student/trainee experience was optimal. • Plan the next session. *An example of “wave” scheduling: the clinician sees patients 1 and 2 while the student sees patient 3, then the clinician joins the student and they jointly see patient 3. In this way, the clinician sees his or her own patients as well as ◆ the ones the learner has just seen.

Planning Key factors of teaching and learning in ambulatory settings include: • Defining the outcomes (including unique ones available in the community setting).4,11 These may include managing common presentations and understanding the role of the practice nurse. Discussion of outcomes with the learner will allow joint expectations to be explored. • Good orientation to the practice, patient care, learning and resources.3,4,13 If this is the learner’s first experience in a community setting, he or she may not be used to exposure to multiple social and often emotional aspects of patients’ lives.4 Orientation helps learners to have the confidence and competence to be involved. Learning Learners should be active members of the team, which means you need to provide them with authentic patient experiences.3,5-7 Trainees initially may value simply watching and learning from role

MJA • Volume 185 Number 3 • 7 August 2006

T E A CH I N G O N TH E R U N

2 Strategies for joint consultation with clinician and student present3-5,10,13,14

Take-home message

• Before the observed consultation, give the learner a framework for thinking, and discuss his or her reflections later.

• Remember that planning and orientation are essential.

• Watch the learner take the history or perform the physical examination, and provide feedback.

• Ensure the learner has good patient contact, with an adequate number and variety of patients.

• Use structured frameworks for teaching (eg, the “one-minute teacher”, the “SNAPPS” approach*).

• Ensure the learner has access to you for discussion, feedback and ◆ some protected teaching time.

When teaching in outpatient settings: • Consider what outcomes are unique to your setting.

• Ask the learner to look up medications or side effects during the consultation. • Get the learner to provide the information on lifestyle changes (eg, smoking cessation). • Get the learner to record observations in the patient notes. * SNAPPS: Summarise the case, Narrow the differential diagnosis, Analyse the differential diagnosis, Probe the teacher about areas of uncertainty, Plan ◆ management, and Select an issue for self-directed learning.

modelling by clinicians, but soon they will want to take responsibility for interaction with patients.3,4 Encourage learners to consider why a particular patient is coming to the clinic, provide guidance as to how long they should spend with a patient, and tell them that interaction needs to be focused rather than extensive. At the same time, ensure they are not missing important aspects of the consultation by focusing too much on one area. Consider what types of patient are appropriate for trainees’ learning needs (eg, in health care assessment, chronic disease management and aged care). Teaching with or in front of patients, such as when the trainee sees the patient alone first and then presents and plans management in front of the patient, doesn’t add much time to the clinician’s work, but significantly increases the time the patient spends with the health care team.2 This requires the use of a second room and flexibility in patient scheduling (eg, “wave” scheduling [see Box 1 footnote]3). In general, clinicians tend to extend their workday by 30–50 minutes per half day to accommodate this type of teaching arrangement, rather than reduce their clinical load.2 Depending on the learner’s level of experience, you may wish to: • Jointly review the patient after the initial review or get the learner actively involved during the consultation (when teaching students) (Box 2); or • Provide advice outside the door on each patient, and/or followup at the end of the clinic (when teaching trainees). Trainees generally prefer to work alone and do not like having the supervising doctor come in and review the patient with them, feeling that it changes the doctor–patient relationship they have established.7 But they do want input. Identify areas of uncertainty for learners, help them find resources, and agree on a time for follow-up. Students and trainees value formalised time for teaching, so set aside an hour a week for that purpose. Appraisal and assessment Learning in clinics can be challenging. In an outpatient setting, learners may find themselves alone with patients, as opposed to a hospital setting, where there are often other people available to give advice. Furthermore, direct observation of trainees in outpatient settings is harder, even though it is important for determining their strengths and areas for improvement. You may wish to sit in with the trainee for a clinic every few months. Gather feedback from others (the receptionist often knows whether patients want to see your

trainee again!).3 Finally, self-reflection by the teacher on individual teaching encounters and on the entire attachment will improve subsequent teaching. Acknowledgements We would like to thank the teachers and participants in Teaching on the Run courses for their input, and the Medical Training Review Panel, Australian Government Department of Health and Ageing, for funding support.

Competing interests None identified.

Author details Fiona R Lake, MB BS, FRACP, MD, Associate Professor in Medicine, and Head, Education Centre, Faculty of Medicine and Dentistry Alistair W Vickery, MB BS, FRACGP, Associate Professor in General Practice, School of Primary, Aboriginal and Rural Health Care University of Western Australia, Perth, WA. Correspondence: [email protected]

References 1 Howe A. Education in family medicine — gains and dangers [editorial]. Croat Med J 2004; 45: 533-536. 2 Bowen JL, Irby DM. Assessing quality and costs of education in the ambulatory setting: a review of the literature. Acad Med 2002; 77: 621-680. 3 DeWitt D. Incorporating medical students into your practice. Aust Fam Physician 2006; 35: 24-26. 4 Howe A. Twelve tips for community-based medical education. Med Teach 2002; 24: 9-12. 5 Dent JA, Ker JS, Angell-Preece HM, Preece PE. Twelve tips for setting up an ambulatory care (outpatient) teaching centre. Med Teach 2001; 23: 345-350. 6 Irby DM. Teaching and learning in ambulatory care settings: a thematic review of the literature. Acad Med 1995; 70: 898-931. 7 Schultz KM, Kirby J, Delva D, et al. Medical students’ and residents’ preferred site characteristics and preceptor behaviours for learning in the ambulatory setting: a cross-sectional survey. BMC Med Educ 2004; 4: 12. 8 Boendermaker PM, Ket P, Dusman H, et al. What influences the quality of educational encounters between trainer and trainee in vocational training for general practice? Med Teach 2002; 24: 540-543. 9 Riesenberg LA, Biddle WB, Erney SL. Medical student and faculty perceptions of desirable primary care teaching site characteristics. Med Educ 2001; 35: 660-665. 10 Lake FR, Ryan G. Teaching on the run tips 4: teaching with patients. Med J Aust 2004; 181: 158-159. 11 Lake FR, Ryan G. Teaching on the run tips 12: planning for learning during clinical attachments. Med J Aust 2006; 184: 238-239. 12 Ferenchick G, Simpson D, Blackman J, et al. Strategies for efficient and effective teaching in the ambulatory care setting. Acad Med 1997; 72: 277-280. 13 Irby DM, Bowen JL. Time efficient strategies for learning and performance. Clin Teach 2004; 1: 23-28. 14 Furney SL, Orsini AL, Orsetti KE, et al. Teaching the one minute preceptor. A randomised controlled trial. J Gen Intern Med 2001; 16: 620-624. (Received 21 Apr 2006, accepted 13 Jun 2006)

MJA • Volume 185 Number 3 • 7 August 2006



167